Wyoming Department of Transportation



|Wyoming Department of Transportation |[pic] |DO NOT WRITE IN THIS SPACE |

|Fuel Tax Administration | | |

|Licensing Section | | |

|5300 Bishop Blvd. | |Date Issued:_______________________________ |

|Cheyenne, Wyoming 82009-3340 | | |

|Phone (307) 777-4826 | |Person Who Issued License:__________________ |

|Fax (307) 777-4769 | | |

| | |License Number:___________________________ |

|$25.00 fee per fuel type. Each dealer location | | |

|requires a separate license. Make checks payable to | |Check No: ________________Amount:_________ |

|Wyoming Department of Transportation. | | |

| | |Expiration Date:___________________________ |

WYOMING MOTOR FUEL LICENSE APPLICATION

RENEWAL APPLICATION

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*** SECTION (A) LICENSE & FUEL TYPE ***

➢ Please check the license type and fuel type(s) that accurately apply to your business operation(s).

➢ Please type or print legibly. If any portion of the application is not complete or if the improper fee is sent, the application may be returned to you for correction, delaying the issuance of your license(s).

➢ The annual fee for the license(s) will be twenty-five dollars ($25.00) per fuel type per location.

➢ All tax returns or dealer reports must be current with our office before issuance of license.

_____SUPPLIER: Means a person that is subject to fuel tax laws of this state, registered with the Internal Revenue Service for transactions of motor fuel in the bulk transfer/terminal distribution system, and the position holder in a terminal or refinery in or outside of Wyoming. A Supplier is also a person who produces alcohol for blending with gasoline.

_____DISTRIBUTOR: Means any person, other than a dealer, who receives fuel or blends fuel for distribution or resale in this state.

_____IMPORTER: Means any person, other than a Supplier, who purchases fuel outside of Wyoming for the purpose of transporting or delivering, other than in the supply tank of a motor vehicle, the fuel into Wyoming for sale, use or distribution within Wyoming.

_____EXPORTER: Means any person, other than a Supplier, who purchases fuel inside of Wyoming for the purpose of transporting or delivering, other than in the supply tank of a motor vehicle, the fuel to another state or jurisdiction.

➢ The license fee for a dealer is in addition to, and not included in, any other license type listed above.

➢ A separate license will be issued for EACH dealer location.

➢ The annual fee for EACH dealer location is twenty-five dollars ($25.00), per fuel type, per location. (Regular, Premium, and Gasohol are all considered gasoline, Aviation Fuel is also considered gasoline). (Jet Fuel is considered Diesel)

_____DEALER: Means any person who sells or offers to sell gasoline or diesel fuel at a specific location in Wyoming, including any person selling or offering to sell aviation fuel at a Wyoming airport. (Includes retail locations such as gas stations, key locks, card locks, and Fixed Base Operators at airports)

FUEL TYPE:

A.) Gasoline _____ B.) Diesel ______ C.) Ethanol______

(Includes Aviation Gas type fuel, and Gasohol) (Includes Kerosene and Jet Fuel)

1. Indicate projected number of gallons to be sold on an average monthly basis:

Gasoline__________gal. Aviation Fuel__________gal. Jet Fuel__________gal. Undyed Diesel__________gal. Dyed Diesel__________gal.

2. List total capacity of storage for fuel type(s) in Wyoming for each type of fuel per location.

Gasoline__________gal. Aviation Fuel__________gal. Jet Fuel__________gal. Undyed Diesel__________gal. Dyed Diesel__________gal.

3.) Physical address, location, and type of bulk storage: ______________________________________________________________________

3a.) If you have acquired additional bulk storage in Wyoming, please list the physical address, location, and type of bulk storage acquired:

____________________________________________________________________________________________________________________

(You must enclose color photos and a legal description of your additional bulk storage plant(s) with this application.)

*************************************** SECTION B ************************************

You must maintain an active status with the Wyoming Sec. of State’s Office (307) 777-7311 (LLC, Corp, Limited Partnership).

Please list your current Fuel Tax License Number here: ___________________________________________________

1.) Have you added or deleted locations or fuel types? ___________ If yes, please explain: _______________________________________

___________________________________________________________________________________________________________________________________

2.) Please indicate type of ownership for this business: ________________________________________________________________________

(Corporation, LLC, Limited Partnership, Sole Proprietor, General Partnership, other)

2a.) Do you currently have an active status and good standing with the Wyoming Sec. of State’s Office? _______ Yes _______ No

3.)_________________________________________________________________________________________________________________________________

Legal Name of Applicant (Corporate, LLC, Partner, or Individual Name)

4.)_________________________________________________________________________________________________________________________________

DBA / Trade Name (Name Under Which Business Will be Operated)

5.)_____________________________________________________________________________________ _______________________________________

Mailing Address E-Mail Address

5a.)________________________________________________________________________________________________________________________________

City County State Zip Code

6.)____________________________________________________________________________________________ Inside City Limits? ____Yes ____ No

Physical Address of Place of Business (NO POST OFFICE BOXES, attach additional pages, if necessary)

6a.)________________________________________________________________________________________________________________________________

City County Zip Code

7.)_________________________________________________________________________________________________________________________________

Telephone Number Your Toll Free Number (If applicable) Fax Number

8.)_________________________________________________________________________________________________________________________________

Contact Person For Business Phone Number Title

9.) Federal Employer Identification Number (FEIN) for the Person, Company, or Entity renewing this License: __________________________

(If this number has changed, you must include documentation from the Internal Revenue Service with your motor fuels application.)

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

I declare that everything contained on this application is a true and accurate statement. I, as owner, co-partner, or officer of the corporation, have the authority to sign this application. I understand as a new applicant a BOND may be required if this application is approved. The bond MUST be on file with the Department before a fuel license will be issued.

SIGNED: ________________________________________________________________TITLE: __________________________

PRINTED NAME: ________________________________________________________DATE: ___________________________

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